The Central-Splitting Approach for Achilles Insertional Tendinopathy and Haglund Deformity

Abstract

Background: Insertional Achilles tendinopathy causes posterior heel pain at the insertion of the Achilles tendon, often in combination with a calcaneal exostosis, or Haglund deformity. Insertional Achilles tendinopathy often presents with a posterior osseous prominence and leads to calcification of the Achilles tendon 1. Nonoperative treatment of these conditions includes activity modification, nonsteroidal anti-inflammatory agents, heel lifts, shoe modification, physical therapy focused on eccentric strengthening exercises, iontophoresis, and shock wave therapy. Nonoperative treatment will fail in approximately 50% of these cases, and such patients become candidates for surgical intervention 2,3. Multiple surgical approaches have been described, including the medial J-shaped, lateral, Cincinnati transverse, double incision, and central-splitting approaches 4. Currently, there is no consensus regarding the ideal approach. Recent literature has suggested that the central-splitting approach allows for adequate exposure of both the most commonly diseased area of the tendon and the calcaneal exostosis, with excellent postoperative pain and functional results 5-13. Description: Place the patient in the prone position with the feet at the edge of the operating table. Make a full-thickness, 5 to 7-cm longitudinal incision centered over the Achilles tendon and the posterior aspect of the calcaneus. Make a central incision through the Achilles tendon. Sharply mobilize the medial and lateral slips and excise the diseased portion of the Achilles tendon. Expose the calcaneal exostosis and perform the calcaneal exostectomy with a microsagittal saw. Repair the remaining healthy-appearing Achilles tendon to the calcaneus with 2 suture anchors. An additional suture anchor or, alternatively, the double-row technique for the Achilles tendon repair may be used. Repair the central split in the Achilles tendon with absorbable suture. Close the soft tissue and skin in layers. Alternatives: Alternative approaches include the medial, lateral, or Cincinnati transverse incisions. The central-splitting approach is favored because of Disclosure: The authors indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSEST/A288).

Patient-Reported Outcomes of Surgically Treated Insertional Achilles Tendinopathy

“…A recent paper concluded that the MITA approach for IAT "appears to be safe and yields satisfactory results." 9 This is in line with previous studies, 3,8 but these had limited sample sizes (22-43 patients) and their conclusions were solely based on the mean PROM values. The reported ranges and standard deviations revealed that a considerable proportion of patients remain symptomatic.…”

Haglund Deformity: Diagnosis and Treatment

“…11 Nonetheless, conservative therapy will fail in almost half of patients, especially those with retrocalcaneal bursitis and/or Achilles insertional tendinopathy. 11,19 Conservative therapy is considered failed if unresponsive after six months. Surgical management is the following line of treatment.…”

A comparative study of single-vs. double-row technique in surgical treatment of insertional Achilles tendinopathy

“…A sterile dressing was applied to the wound, and the leg was immobilized with a dorsal plaster splint or cast placed at 15-20o with the ankle in in the equinus position. The tourniquet was then deflated and the patient was placed in the supine position (13,17) . Non-functional immobilization was used during the postoperative period.…”

“…From the sixth to the eighth week, the wedges were gradually removed and physical therapy was begun. Finally, the boot was removed after the eighth week (17) .…”

“…Surgery should be considered only when conservative treatment (a maximum of six months) has failed or in cases of persistent pain and limitations in daily and sports activities (1,14,16) . Two of the surgical techniques cited in the literature for tendinopathy are single-row repair with two anchors (17) and double-row repair with four anchors (18) . J Foot Ankle.…”